HEDIS Compliance: Why and How Exceeding HEDIS Measures is Vital for Your Practice

Health Effectiveness Data and Information Set (HEDIS) are measures set by the Centers for Medicare and Medicaid Services (CMS) to define and measure the care services provided under Medicare. HEDIS provides a universal framework for all providers who participate in Medicare. HEDIS is updated regularly, and providers need to be sure they are offering HEDIS-aligned services to maintain eligibility for full Medicare reimbursements.

What Is the Purpose of HEDIS?

The Health Effectiveness Data and Information Set, or HEDIS, is a set of standardized performance measures managed by the National Committee for Quality Assurance (NCQA). The measures are to evaluate insured patients’ quality of care and services. 

The Centers for Medicare and Medicaid Services (CMS) contracted the NCQA to create a five-star quality rating system to gauge how well providers and health plans deliver care, with a rating of five being excellent and one being poor. The CMS HEDIS standards also measure the effectiveness of special needs plans (SNPs) addressing common public health issues like asthma, cancer, heart disease, diabetes, and more. 

What Are HEDIS Measures? 

The HEDIS measurement system assesses the quality of healthcare based on over 90 measures across six domains of care: 

• Effectiveness
• Availability
• Experience
• Utilization/risk-adjusted utilization
• Health plan descriptive information
• Measures reported using electronic clinical data systems. 

CMS and NCQA use HEDIS scores to evaluate the quality of healthcare services and compare performance from plan to plan.  Health plans participate in the HEDIS review process by submitting medical records, administrative data, and other supplemental information. HEDIS reporting data is used to assess how healthcare plans and practices are meeting benchmarks for care delivery.

As of now, 90% of Medicare, Medicaid, and commercial health plans in the US participate in HEDIS review by submitting medical records, administrative data, and other supplemental information. By reviewing medical data, HEDIS can assess how healthcare plans and practices are meeting benchmarks for care delivery.  

Why Is HEDIS Important?

HEDIS’ primary goal is to improve preventative care. Preventative care includes routine screenings for common medical conditions, which results in better health outcomes and reduced healthcare costs. 

HEDIS aims for providers and insurers to achieve compliance in all six domains of care.

To encourage providers and health plans to meet HEDIS standards, CMS offers pay-for-performance incentives to participating organizations that are meeting standards of care. CMS defines these incentives as “the use of payment methods and other incentives to encourage quality improvement and patient-focused high-value care.” 

HEDIS in Healthcare for Diabetic Care

Managing diabetes and preventing complications from diabetes is a growing priority within the healthcare community. The prevalence of diabetes in the United States is evident, though its harmful side effects are often understated. In 2021, 38.4 million people in the United States had diabetes, with an additional 8.7 million undiagnosed. In addition, 97 million adults were diagnosed with pre-diabetes. 

Furthermore, of US adults aged 18 or older, 96 million were diagnosed with pre-diabetes, equaling 38% of the adult population. 

While the prevalence of diabetes in the United States is evident, its harmful side effects are often understated. Diabetes complications can result in anemia, kidney disease, high blood pressure, and diabetic retinopathy—which can lead to blindness if it isn’t diagnosed and treated early on.

HEDIS diabetes measures seek to minimize diabetes-related complications. HEDIS-compliant comprehensive diabetic care standards suggest that US adult diabetics ages 18-75 should undergo annual screenings, including: 

• Hemoglobin A1c testing 
• Retinal eye exam 
• Nephropathy (kidney disease monitoring)
• Blood pressure control 

Multiple factors can play into an organization’s HEDIS compliance scores, including easy access to testing for patients, the effectiveness of the testing itself, and a patient’s care experience with their primary medical physician. 

HEDIS Measures for Diabetic Retinopathy

Diabetic Retinopathy (DR), a complication of diabetes, is characterized by damage to the small blood vessels present in the retina, usually due to high blood sugar levels. DR has two main stages: non-proliferative DR, which can cause slight blurring of vision, or proliferative DR, which can lead to complete vision loss. 

In 2021, researchers estimated that 9.60 million people in the US had diabetic retinopathy with 1.84 million people having vision-threatening diabetic retinopathy. Moreover, diabetes-related complications are now the leading cause of blindness among adults aged 18-64 years of age. This is preventable; negative outcomes from diabetic retinopathy can be averted through careful monitoring, including yearly retinal exams.

The value of retinal exams is why HEDIS compliance measures for comprehensive diabetic care include a retinal eye exam. These exams can be provided by an eye care specialist or via remote teleretinal screening. Teleretinal screenings allow primary care providers and other healthcare entities to offer retinal screenings so patients don’t need to schedule a separate specialist visit.

Adding HEDIS-compliant retinal screening capabilities in primary care and clinic settings increases patient access to diabetic retinopathy screenings and boosts provider HEDIS ratings.  

IRIS For HEDIS Compliance

The IRIS solution provides retinal screenings without the need for a dilated eye exam by an ophthalmologist. IRIS integrates with retinal camera systems to capture images of a patient’s retina. Providers can automatically and securely upload the images to the IRIS platform. 

Board-certified eye care professionals at the IRIS Reading Center (IRC) review the images and note the possible presence of diabetic retinopathy or macular edema. If there is an indication of eye pathology, patients are referred to an eye specialist for further exams and possible treatment.

Teleretinal screenings allow providers to offer HEDIS-compliant diabetic retinopathy screenings from primary care providers, mobile health clinics, or home health care providers, which increases patient access to screenings. As a result, providers can report to HEDIS that patients have received screenings as part of their diabetic care. 

It is a win-win approach for both patients and practices— quality care is easily administered to patients while practices meet HEDIS requirements and receive financial compensation for doing so. 

IRIS technology increases the ease of access to retinal exams for patients, encouraging greater willingness to complete them while also improving your practice’s HEDIS compliance measures.

Is IRIS Right for You?

All patients with diabetes and pre-diabetes should receive yearly retinal examinations to prevent the progression of diabetic retinopathy. However, only 40-50% of the diabetic population follow through with them annually.

Diabetes is one of the most prevalent health issues in the United States, and as the diabetic population grows, undiagnosed cases of diabetic retinopathy continue to threaten the vision of adults across the country. According to the CDC, more than one in ten Americans has diabetes.

The American Diabetes Association (ADA) states, “[the data] show an alarming increase of diabetes in our nation among young adults,” while the high number of unknown pre-diabetics “is fueling the diabetes epidemic.” 

All patients with diabetes and pre-diabetes should receive yearly retinal examinations to prevent the progression of diabetic retinopathy. However, only 40-50% of the diabetic population follow through with them annually. 

This is a negative outcome for patients and providers alike. As one of the primary HEDIS compliance measures for comprehensive diabetic care, we need innovative solutions to ensure that all diabetic patients complete their annual retinal exams. 

IRIS allows practices to do just that by implementing diabetic retinal examinations in primary care or home healthcare settings. This eliminates the need for patients to book additional appointments or travel to see specialists. In addition, IRIS professionals provide exam results quickly, allowing your practice to quickly and easily reach HEDIS standards while providing better quality, convenient care for your patient population and maximizing Medicare reimbursements.

Still, it is crucial to know how IRIS can fit into your organization. Use our return on investment calculator here to understand how IRIS can benefit your practice.

As you seek solutions to improve your practice’s HEDIS compliance ratings, reach out to us for more information on how IRIS can be integrated into your organization to work towards all-inclusive and successful diabetic care.

 

FAQs

What quality measures are relevant to diabetes?

HEDIS measures for diabetes are:

• Hemoglobin A1c (HbA1c) testing.
• HbA1c poor control (>9.0%).
• HbA1c control (<8.0%).
• Eye exam (retinal) performed.
• Medical attention for nephropathy.*
• BP control (<140/90 mm Hg).

What is the HEDIS A1C for diabetes?

HEDIS considers HbA1c >9.0% as poorly controlled and HbA1c <8.0% as controlled.

What is the HEDIS measure for HbA1c poor control?

HEDIS considers HbA1c >9.0% as poorly controlled.

What CMS domain does HEDIS fall under?

CMS contracts with the National Committee for Quality Assurance to develop HEDIS measures. 

How does CMS collect data for star and HEDIS ratings?

NCQA collects a portion of HEDIS data directly from health plans and preferred provider organizations (PPOs) through the Healthcare Organization Questionnaire. In addition, it collects non-survey data through the Interactive Data Submission System.

What are HEDIS measures?

HEDIS measures are a centralized set of standards applied to Medicare care delivery. Care providers are encouraged to offer the full range of applicable HEDIS services to their patients.

What is the purpose of HEDIS?

Setting universal guidelines for care ensures that all providers offer the same services to Medicare patients. It reduces care disparities and ensures that patients receive the services they need for optimal health.

Why is HEDIS important?

Meeting HEDIS goals is important for care providers because it can impact Medicare reimbursement rates. CMS offers high reimbursement levels for providers who score well on HEDIS reviews.

How to calculate HEDIS score?

Providers and health plan systems submit data to NCQA for review. NCQA calculates their score based on claim data submitted to the health plan and a sample of medical record data.

What is a good HEDIS score?

HEDIS measures are scored on a five-star scale. A rating of five is considered excellent, and a rating of one is considered poor.

 

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 SM 112, Rev C